Beyond the numbers – Reviewing maternal deaths and complications to make pregnancy safer
Ramachandran, Prema
Beyond the numbers – Reviewing maternal deaths and complications to make pregnancy safer (World Health Organization, Geneva) 2004. 142 pages. Price: US $ 22.50; in developing countries: CHF 17.50 ISBN 92 4 159183 8
Pregnancy is a normal healthy state which most women look forward to at some period of their life. But this normal life giving process can carry serious risks to the mother. It is estimated that every year over eight million women suffer from pregnancy related complications and about half a million mostly from developing countries, die. Maternal mortality offers a litmus test for assessing the status of women, their access to health care and adequacy of the health systems response to meet their needs. International Conference on Population and Development (Cairo 1994), Fourth World Conference on Women (Beijing 1995) and the Millennium Declaration (New York 2000) have emphasized need to improve maternal health and avert maternal deaths. However, the available meager data suggest that very little progress has been achieved over the last decade.
One of the major problems in assessing the progress in averting maternal deaths and severe morbidity is lack of well established civil registration system in developing countries where majority of the maternal deaths take place; because of this problem, measurement of differences in maternal mortality rates over time between different regions and in response to changes in health care delivery is rather difficult in developing countries. While embarking on studies on maternal deaths it is also important to keep in mind that the major rationale for the studies on maternal deaths is to learn how to prevent them. To achieve this, it is essential to go beyond just measuring the numbers and rates, and find the causes of death, ensure that none of these women have died in vain, by putting in place necessary tools to prevent future maternal deaths.
Concerned over the continued high maternal mortality rates in developing countries, WHO Headquarters had organized a series of inter- regional consultations in Geneva in 1998 and 1999 on monitoring maternal deaths. During these consultations, the participants emphasized that while the efforts might begin with measuring number of maternal deaths, these should progress towards assessment of the underlying causes of death and how to prevent them. The importance of developing guidelines that can be followed by countries which are embarking on this essential but far from easy task was emphasized. In response to this, the Department of Reproductive Health and Research of the WHO published this guide for generating information on maternal outcomes and maternal health care.
It is stated in the Introduction that the data collection instruments and guidelines are provided as examples which investigators may wish to use while developing their own maternal death review process, forms, audit sheets, and questionnaires. The intention is not to prescribe a standard instrument but rather to provide the reader with ideas, options, and choices in developing their own process of reviews as well as data collection instruments.
The book provides detailed description of data collection instruments for five commonly used approaches for generating data on maternal mortality. There are Community-based maternal death reviews (verbal autopsies), Facility-based maternal death reviews, Confidential enquiries into maternal deaths, Surveys of severe morbidity (near misses), and Clinical audit.
There are detailed discussions on prerequisites for each of these approaches for review of two specific health outcomes- maternal deaths and life threatening complications, and one process-clinical care; how these reviews can be conducted at community, health care facility, district or national level; and relative merits of each method and their limitations, e.g., maternal deaths can be reviewed at all levels; clinical practices are best assessed at facility level; review of life-threatening complications at community level may be quite difficult because of difficulties in correctly ascertaining severity of the complications from lay reporting.
The advantages and disadvantages of using each approach, how relevant information can be ascertained from the family, community, health care provider, programme manager and policy maker, principles to be followed in deciding which approach should be preferred is dealt with extensively in the chapter on the approaches. The next chapter is devoted to stepby-step description of practical issues in implementing the approaches.
The chapter on verbal autopsies explains how this technique can be very useful in settings where large numbers of maternal deaths are occurring outside health facilities. From the family and community it is possible to find out whether the women and the community know that they have to get health care during pregnancy; were they aware of danger signals and did they know where to go if they had problems; and did the community play its role in ensuring that these women reached at the appropriate health facility in time.
Though ascertainment of actual causes of maternal deaths through verbal autopsy may lack precision , it is a valuable tool for identifying areas that require immediate intervention ranging from improving awareness about danger signals, improving transport to improving hospital facilities.
An entire chapter is devoted to maternal death review in the health facilities. The emphasis is on undertaking a maternal mortality audit in a confidential, non judgmental, non threatening environment, solely for the purpose of improving service delivery by ascertaining the cause of death; reason for unability to provide approprieate care at appropriate time; and finding the key interventions at service delivery level to prevent similar deaths. Several exasmples of facility-based case studies in developing countries and how these can provide valuable leads for improving the facility are given in this chapter.
One full chapter is devoted to confidential enquiries into maternal deaths which describes key principles, advantages and disadvantages of the method and how the findings can be used to obtain answers to the questions such as: (i) what were the barriers to seeking appropriate health care?; (ii) what were the things that went wrong?; and (iii) what are the steps to be taken to avert similar deaths in future?
There is one chapter on reviewing severe maternal morbidity and learning form survivors of life-threatening complications. This chapter describes in detail the principles, step-by-step process of undertaking the near miss reviews and the major advantages of this method. This is not widely used in developing countries because of inherent problems in ascertaining what a near miss situation is when many deaths are not occurring in hospitals.
The last chapter is on clinical audit and learning from systematic case reviews assessed against explicit criteria. This audit is complementary to the facility-based maternal death reviews. This chapter provides how a beginning can be made towards using this method in developing countries. The simple act of establishing criteria for defining good practices may have a major impact on current practices by providing evidence-based norms for interventions in each setting. Consistent efforts to review the situation will also alert the health care providers regarding the extent to which they are failing to implement good practice. Such reviews may help in sensitizing the programme mangers and policy makers about health system reforms needed to prevent maternal deaths.
In each chapter several examples of the reviews of maternal mortality and life threatening situations from different countries along with comments on their applicability in different situation are given. The book clearly brings out the fact that by spending some of the resources towards ascertaining the reason for high maternal deaths, it will be easy for developing countries to make optimal use of the remaining resources to undertake interventions to avert maternal deaths.
Prema Ramachandran
Nutrition Foundation of India
C-13, Qutab Institutional Area
New Delhi 110016, India
Copyright Indian Council of Medical Research Jul 2005
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